Inspection on 27/10/05 for Martin Hall Nursing Home

This inspection was carried out on 27th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Martin Hall Nursing Home 06/07/06

Martin Hall Nursing Home 22/04/05

Martin Hall Nursing Home 19/08/04

Martin Hall Nursing Home 29/04/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Martin Hall Nursing Home The Old Hall Martin Lincs LN4 3QY Lead Inspector Mrs Sue Daniells Unannounced Inspection 27th October 2005 11:40 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Martin Hall Nursing Home DS0000002543.V260541.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Martin Hall Nursing Home DS0000002543.V260541.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Martin Hall Nursing Home Address The Old Hall Martin Lincs LN4 3QY Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01526 378251 01526 378250 info@martinhall.co.uk Peck & Packer (Care Homes) Limited Ms Lesley Susan Layton Care Home 40 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (39), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (40) Martin Hall Nursing Home DS0000002543.V260541.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to provide care for service users of both sexes whose primary needs fall within the following categories:Mental Disorder, excluding learning disability or dementia -over 65 years of age (MD(E)) (40). Dementia - over 65 years of age (DE(E)) (39) Dementia - (DE) (2) for service users aged between 60 years and 65 years The maximum number of service users in the home with nursing needs does not exceed 29 and the maximum number of service users with personal care needs only does not exceed 11. 22nd April 2005 2. Date of last inspection Brief Description of the Service: Martin Hall is situated in its own grounds in the village of Martin-byTimberland, which is on the main road between Lincoln and Woodhall Spa. Local amenities include village shop/post office, church, village hall and public house. A local bus service passes through the village every hour and runs between Boston and Lincoln. The home can accommodate up to 40 service users with mental health needs, offering either nursing care or personal care. Bedrooms are on the ground and first floor and comprise 24 single rooms, 15 of which are en-suite and 8 shared rooms, all of which are en-suite. Martin Hall Nursing Home DS0000002543.V260541.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over approximately 4 hours. 28 residents were receiving nursing care and 10, personal care only. The main method of inspection used was “case tracking”. This involved selecting four residents and looking at the care that they received through the checking of their records, discussion with the staff and looking at the care they receive. Discussions were also had with two relatives. Because of the client group cared for at the home, conversation with the residents was very limited. The inspector was also able to see the majority of service users in the home and observe the care that they received from the staff. One of the relatives spoken to stated that they “didn’t think any other specialist unit of this type would look after **** as well as they do here” What the service does well: What has improved since the last inspection? Copies of the contract/terms and conditions are now given to residents or their families and pre-admission assessments have been updated to be more comprehensive. Parts of the home have been decorated and/or refurbished and staff application forms and induction pro-forma’s have been reviewed and altered. Martin Hall Nursing Home DS0000002543.V260541.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Martin Hall Nursing Home DS0000002543.V260541.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Martin Hall Nursing Home DS0000002543.V260541.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 4 Residents are comprehensively assessed before admission and receive assurances that the home can meet their needs, as well as a contract or a copy of the terms and conditions of the home. EVIDENCE: From the files examined it was evidenced that each resident, or their family member, had been given a copy of the terms and conditions of the home on admission. A breakdown of the fees and who was responsible for paying them was part of this document. The home has produced a new pro-forma, which is used for all pre-admission assessments and since the last inspection contains all “good practice” issues highlighted in the last inspection report. Because of some of the complex needs relating to the residents, in most circumstances the home receives detailed information from health professionals, social workers and families before a decision is made as to whether the home can meet someone’s needs. A trained member of staff felt that they knew all the care needs before the admission of a resident. Martin Hall Nursing Home DS0000002543.V260541.R01.S.doc Version 5.0 Page 9 Letters had been sent to all privately funded residents stating that the home can meet their needs, following an assessment by a senior staff member. The inspector was informed that this would now occur for all residents. Martin Hall Nursing Home DS0000002543.V260541.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 9 Care plans are still not written immediately following admission and do not always reflect residents’ needs; residents are therefore at risk. More care is required to ensure that the home’s medication policies are always followed. EVIDENCE: Of the four residents case tracked during the inspection, one resident admitted three weeks prior to the inspection, did not have a care-plan; the staff were writing their observations in the “daily record”. A staff member stated that “it was not good” when this happened. Of the three care-plans examined it was found that one had no record of two areas of concern and the care that was needed by staff. These had been highlighted prior to their admission. Because of the specialised needs of the resident group, it is not possible for residents to self-medicate. The home has policies and procedures for all aspects of medication although medication charts were, once again, not always being signed by staff following administration of drugs. Examination of the controlled drug book showed that two tablets of a Schedule 3 drug had been “loaned” to another resident whose own drugs had not been replenished. This Martin Hall Nursing Home DS0000002543.V260541.R01.S.doc Version 5.0 Page 11 had been rectified the following day. This incident was reported to the manager. The home deals with a contractor for disposal of all waste medicines, including controlled drugs. Martin Hall Nursing Home DS0000002543.V260541.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 15 Residents are helped by staff to choose their own lifestyle preferences and encouraged to participate in meaningful activities. Food is plentiful and well-balanced. EVIDENCE: Residents are helped to make their own choices regarding their lifestyle preferences, which include the time they rise and retire, and any activity they wish to participate in. Currently, the home does not have an activities organiser although the home was undertaking recruitment at the time of the inspection. Art and craft work that some of the residents had participated in was on display in the activity room. During the afternoons and evenings when the home is a little quieter, staff are able to undertake “one-to-one” time with the residents when they sit and chat with them, help with a jigsaw or give ladies a manicure. Staff stated that it was sometimes difficult to find the time to do this and looked forward to the appointment of a new activities organiser. Trips out in the minibus are organised as often as possible. Menus are rotated on a rolling basis and displayed on a notice board. Birthdays are always celebrated with a cake. The kitchen is able to provide for specialised diets and although there is generally only one main meal served at lunch-time with a vegetarian option, the cooks are able to offer a number of Martin Hall Nursing Home DS0000002543.V260541.R01.S.doc Version 5.0 Page 13 alternatives if requested to do so. Staff and the residents spoken to stated that the food was good and there was always a plentiful supply including fresh fruit, which is offered every day. Martin Hall Nursing Home DS0000002543.V260541.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Staff receive training in adult protection and would inform management if suspicious of anything. EVIDENCE: Of the three members of staff spoken to, two had received formal adult protection courses during the year and were aware of the adult protection policy. The third had an awareness of the issues and would be attending a course in the near future. All three staff stated that they would alert management if they became suspicious of anything. Martin Hall Nursing Home DS0000002543.V260541.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Residents live in a safe, clean and homely environment. Effective systems for the removal of malodours are needed. EVIDENCE: On the day of inspection the home was seen to be safe and well maintained with “pad locks” on all external doors to limit inappropriate wandering. Since the last inspection, a number of wardrobes, bed-side tables, chairs and soft furnishings have been replaced and the conservatory is now furnished and heated. The larger dining room, mentioned in the last inspection report, will be equipped with new furniture within the next six months. The home was seen to be clean and a relative stated that ”it’s always clean and tidy when we come”, with laundry undertaken on a daily basis. An infection control policy is in operation. However, a malodour was noticed in parts of the corridors; the manager stated that carpets are cleaned almost every day and specialist sprays are utilised. Martin Hall Nursing Home DS0000002543.V260541.R01.S.doc Version 5.0 Page 16 Martin Hall Nursing Home DS0000002543.V260541.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 and 30 Resident’s needs are met by appropriate numbers and skill mix of staff who are trained and competent to do their jobs with residents being protected by the home’s recruitment processes EVIDENCE: Dependency levels were high and staff duty times had recently changed. The skill mix of trained nurses and carers appeared to be good. Staff stated that problems usually occurred at weekends when it was difficult to replace those who were sick, with one staff member saying that it made a lot of difference when they were “one down” on a shift. They also stated that they felt that the standards of care were good at the home. One relative said “the home always appears to be well staffed and they’re always around if you need them” On the day of the inspection all residents appeared well cared for and staff were able to meet their needs. Files for two members of new staff were examined. All the documentation was in place and the application form for prospective employees now has sufficient space to list all previous employment. Interview notes were not available. Details of training for staff were evidenced in their personal files and included mandatory subjects for example fire training, moving and handling and health and safety as well as specialist training in subjects such as palliative care, dementia and promotion of continence. Staff spoken to felt that they were Martin Hall Nursing Home DS0000002543.V260541.R01.S.doc Version 5.0 Page 18 equipped with the knowledge to care for the residents and meet their needs with one, who has worked at the home for five months stating “I feel confident about my duties and responsibilities”. Relatives spoken to were very complimentary of the care that the staff gave. Martin Hall Nursing Home DS0000002543.V260541.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,36 and 38 The home is run in the best interests of the residents. The health, safety and welfare of both residents and staff are protected and staff feel well supported by management, although formal documented supervision has not commenced. EVIDENCE: The staff and relatives spoken to felt that the home was always run in the best interests of the residents. One staff member stated that the rapport between the staff and the relatives was probably much better than in other homes because of the nature of the illnesses that the residents had. Relative meetings are not held at present although staff meetings are held on approximately a quarterly basis. The inspector was informed that if suggestions are made, the manager will always listen to them and take them forward. Martin Hall Nursing Home DS0000002543.V260541.R01.S.doc Version 5.0 Page 20 Induction for new members of staff is comprehensive and includes a session on dementia awareness with a date set for a more formal and detailed course. One new staff members stated that they had received a lot of input from senior staff about individual residents and knew how to deal with everyone. They had also been “buddied” with a more senior staff member during their initial employment, which was very helpful. All the staff spoken to felt very supported by management; the manager has an “open door” policy of management and staff felt able to approach her at any time to discuss issues. Documented formal supervision for staff has still not commenced. A variety of documentation was examined in relation to safe working practices: these were found to be up-to-date. Martin Hall Nursing Home DS0000002543.V260541.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x 3 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 3 3 x x x x x x 2 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 3 x x 2 x 3 Martin Hall Nursing Home DS0000002543.V260541.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 (1) Requirement The service user plan (care plan) must be formulated as soon as possible after admission and must identify in detail the action which needs to be taken by both qualified and care staff to ensure that all aspects of the health, personal and social care needs of service users are met. Previous timescale of 31.05.05 not met. Staff who administer any form of medication must sign the service users MAR chart immediately following the administration. Previous timescale of 31.05.05 not met. Staff must not give drugs prescribed for one resident to another resident. Documented supervision must take place for all members of staff at least 6 times a year. Previous timescale of 30.12.05 has been extended Systems must be put in place to ensure that malodours are eliminated. Timescale for action 31/12/05 2. OP9 13 (2) 27/10/05 3. 4. OP9 OP36 13 (2) 18 (2) 27/10/05 31/03/06 5. OP26 13 (3) 31/12/05 Martin Hall Nursing Home DS0000002543.V260541.R01.S.doc Version 5.0 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 4. Refer to Standard OP19 OP29 Good Practice Recommendations it is recommended that the dining furniture be replaced within the next six months. Recommendation from last inspection report. As good practice, notes on recruitment interviews should be made. Recommendation from last inspection report. Martin Hall Nursing Home DS0000002543.V260541.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Martin Hall Nursing Home DS0000002543.V260541.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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